User experiences with clinical social franchising: qualitative insights from providers and clients in Ghana and Kenya
By Maia Sieverding, Christina Briegleb and Dominic Montagu from BMC Health Services Research
Clinical social franchising is a rapidly growing delivery model in private healthcare markets in low- and middle-income countries. Despite this growth, little is known about providers’ perceptions of the benefits and challenges of social franchising or clients’ reasons for choosing franchised facilities over other healthcare options. We examine these questions in the context of three social franchise networks in Ghana and Kenya.
We conducted in-depth interviews with a purposive sample of providers from the BlueStar Ghana, and Amua and Tunza networks in Kenya. We also conducted qualitative exit interviews with female clients who were leaving franchised facilities after a visit for a reproductive or child health reason. The total sample consists of 47 providers and 47 clients across the three networks.
Providers perceived the main benefits of participation in a social franchise network to be training opportunities and access to a consistent supply of low-cost family planning commodities; few providers mentioned branding as a benefit of participation. Although most providers said that client flows for franchised services increased after joining the network, they did not associate this with improved finances for their facility. Clients overwhelmingly cited the quality of the client-provider relationship as their main motivation for attending the franchise facility. Recognition of the franchise brand was low among clients who were exiting a franchised facility.
The most important benefit of social franchise programs to both providers and their clients may have more to do with training on business practices, patient counseling and customer service, than with subsidies, technical input, branding or clinical support. This finding may lead to a reconsideration of how franchise programs interact with both their member clinics and the larger health-seeking communities they serve.
Clinical social franchising is a rapidly growing model for delivery of services in private healthcare markets, with 83 programs in operation or planning to launch as of 2013 . Social franchises engage private providers in a contractual arrangement to provide standardized health services under a common brand name [1,2]. Participating providers are offered services such as training, branding and commodity supply, in exchange for which they are expected to provide agreed-upon services, often under certain quality conditions [3,4]. The driving hypothesis behind social franchising is that a network operating under this type of contractual arrangement can deliver improved health services in terms of access and quality . At the same time, providers are expected to benefit from the technical assistance provided by the franchisor, as well as to benefit financially from branding and increased client flows [3-5].
Despite its expanding scale, recent reviews have found limited evidence for the impact of social franchising in areas including health outcomes, quality, utilization and access to family planning services [2,6]. Less attention has been given to provider and client experiences with or perceptions of franchising, factors that are also likely to influence the impact of this delivery model. The few studies that have addressed provider motivations to join or maintain membership in a franchise network have found that providers cite a number of factors, including access to medicines [7-9], social responsibility [7-9], technical improvement [7-10], improved client relationship management  and opportunities for networking [7,9]. There is limited evidence regarding the effect of franchising on service utilization . However, one study found that franchised facilities experienced higher client volumes, suggesting that this could be a financial motivation for joining the network . In Myanmar, franchised providers experienced increases in income , although another study on the same network found that finances were not a main motivation for joining the network and providers were concerned that their revenues might decline due to network limits on profit margins .
While most research on providers’ motivations to join a franchise network is limited to Asia, franchising has been found to increase client satisfaction in several contexts [4,5,11]. Quality of care and a positive provider-client relationship have been found to be important to clients’ choice to attend a franchised provider in Asian contexts [5,8] and among youth seeking family planning services in Kenya . General literature on client satisfaction with private sector health facilities in Kenya and Ghana, our two countries of interest, has found that interpersonal treatment by providers [13,14], the physical environment of the facility [13,15], distance  and wait time [15,16] are important considerations for healthcare users.
Evidence on provider and client perspectives on social franchising in Sub-Saharan Africa, however, is particularly limited. Given that there are at least 43 networks operating in the region , this is an important gap in our understanding of social franchising. The objective of this study was to understand experiences with clinical social franchising, from both the provider and client perspective, in the context of three large networks affiliated with international non-governmental organizations (NGOs) in Ghana and Kenya. On the provider side, we aimed to understand perspectives on the benefits and challenges of participating in a social franchise network. From the clients’ perspective, we aimed to understand factors influencing the choice to attend a franchise facility as compared to other healthcare options.
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